Mental State Exam (MSE) Notes

Patient Information: - John Doe - 45 years old - Male - 1 November 2024 Appearance: - The patient appeared disheveled, with unkempt hair and wrinkled clothing. Hygiene was poor, and there were noticeable signs of self-neglect. Behaviour: - The patient exhibited restless motor activity, frequently shifting in his seat. Eye contact was minimal, and he appeared uncooperative at times. Speech: - Speech was rapid and pressured, with occasional slurring noted. Mood: - The patient reported feeling 'down' and 'hopeless'. - Observed mood was congruent with the reported feelings of depression. Affect: - Affect was flat and restricted, with little variation in emotional expression. - The affect was congruent with the reported mood of depression. Thought: - Thought process was disorganized, with frequent tangential thinking. The patient expressed delusional beliefs about being monitored by unknown entities. Perception: - The patient reported auditory hallucinations, describing voices that were critical and derogatory. Cognition: - The patient was oriented to person but disoriented to time and place. Memory recall was impaired, and attention was fleeting. Insight: - The patient demonstrated limited insight into his condition, expressing skepticism about the need for treatment. Judgment: - Judgment was impaired, as evidenced by the patient's inability to recognize the potential consequences of his actions, such as neglecting personal hygiene. Counselor Information: - Dr. Thomas Kelly - Licensed Professional Counselor - 1 November 2024